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The Daily - June 16, 2010
Centennial winners: Health Minister Leona Aglukkaq and CPHA Chair Dr. Cory Neudorf present the prestigious R.D. Defries Award to Chief Public Health Officer Dr. David Butler-Jones (l) and Dr. Marie des Anges Loyer.
 

Butler-Jones, Loyer share CPHA’s Defries Award

Two past presidents of the Canadian Public Health Association shared the prestigious R.D. Defries Award and three distinguished individuals were named national public health heroes when CPHA celebrated its 100th anniversary at the Centennial Gala Dinner last night.

Dr. David Butler-Jones, appointed Canada’s first chief public health officer in 2004, played a central leadership role in the revitalization of public health in Canada. Dr. Marie des Anges Loyer, a public health nurse who eventually became dean of the University of Ottawa School of Nursing and associate dean of its Faculty of Health Sciences, served as a volunteer leader with numerous national and local agencies.

The 2010 National Public Health Hero Award went to anti-tobacco activists Robert Cunningham, Louis Gauvin, and Gar Mahood.

Charlene Beynon and Dr. Clyde Hertzman received Honorary Life Memberships, while Dr. Anna Banerji, Dr. Dexter Harvey, and the late Betty Burcher were awarded the Certificate of Merit. Prof. Ronald Labonté won the CPHA International Award, the Ontario Healthy Communities Coalition received the Ron Draper Health Promotion Award, and the Public Health Human Resources Award went to the Canadian Institute of Public Health Inspectors (for organizations) and Claire Betker (for individuals).

The Ts’ewulhtun Health Centre received the CPHA-Amgen Award for Innovation in Family Health and Angela Mashford-Pringle won the Dr. John Hastings CPHA Student Award. Other student awards went to Lisa Nobel, Dorian Watts, Ananya Banerjee, Kate Zinszer, Fabian Besner, Kora DeBeck, Erica Pufall, and Jena Webb.

 

Panel explores inequalities for marginalized populations

Dr. Marcia Anderson
Session moderator Dr. Georges Benjamin, executive director of the American Public Health Association, brought anniversary greetings from his organization’s 50,000 members.

“Health is fundamentally a social phenomenon.”
“Anniversaries are an important opportunity for you to reassess the past, take measure of the present, and predict the future,” he said, and “the best way to get to the future is to invent it yourselves.”

Dr. Marcia Anderson, past president of the Indigenous Physicians Association of Canada, said she would soon give birth to a baby whose life expectancy would be significantly lower than the Canadian average. In the Cree tradition, she said, early childhood “is the most critical stage of life, when people are closest to the spirit world,” the time when people “form their sense of self, their sense of purpose, their sense of community, and their sense of belonging.” That means everything parents expose themselves to, or to which they’re exposed, has an impact.

In The Halls
What do you see as the greatest public health achievement of the last century, and what are the biggest challenges ahead?

“The advance in tobacco control is something people can really hang their hats on. There was a great mass of clinically based evidence, and there was the passion and advocacy to move the agenda forward. It was a comprehensive approach. The challenge in the future is to take that model to other issues that might be politically uncomfortable right now, but need the same passion and advocacy. For alcohol, for example, let’s not wait 30 years.”
—Halifax

“It’s not just the food, the alcohol, the cigarettes, the pollution that the mother takes in that affects the baby,” she said. “It’s the very society she’s living in.”

Noting that Canada’s history with and policies toward its indigenous people fit the definition of colonialism, Dr. Anderson called for a zero-tolerance policy on individual racism and the “institutional racism that exists in this country.”


“We no longer need to go to the reports to pull that information out, because we know it...”
Dr. Paulo Buss, president of the World Federation of Public Health Associations (WFPHA), congratulated CPHA on its centennial and Global Health Director Jim Chauvin on his election as WFPHA’s president beginning in 2012. Dr. Buss noted that health is “fundamentally a social phenomenon,” so that “the core of public health strategy is to adequately address the social determinants of health.”

The extremes of globalization “have created large international disparities and huge social and health problems,” he said, particularly in countries that are “excluded from the central axis of the global economy.” Large proportions of the global population face food insecurity, climate change, and an array of health problems including hepatitis C, HIV/AIDS, malaria, tuberculosis, cardiovascular disease, cancer, and social violence.

Dr. Buss cited south-south co-operation, effective use of “soft power,” and implementation of global agreements as factors that could shape a more equitable international approach to health.


Angela Robertson and Dr. Paulo Buss
Angela Robertson, director of equity and community engagement at Women’s College Hospital in Toronto, gave a “roll call” of the health and social challenges facing marginalized urban populations, especially women. Her list included higher poverty rates and income inequality for women—especially racialized women—and high reliance on social assistance. In Toronto in 2001, 43% of recent immigrants spent more than half their household income to rent overcrowded living units in dire need of repair.

 “We no longer need to go to the reports to pull that information out, because we know it,” Robertson said. “It’s something that has become so known that is now almost taken for granted, but there is no targeted response or strategy to change it.” Public health’s role is to foster the preconditions for social and community health by responding to health inequalities.

 

Changing recommendations hindered H1N1 messaging

Pregnant women received conflicting, confusing information on vaccine options during last year’s H1N1 pandemic, and a breakout panelist Tuesday morning questioned whether public health practitioners are asking the questions that will help them learn from the experience.

Going into the 2009 H1N1 season, pandemic planners knew that pregnant women had a history of refusing annual flu shots, despite strong evidence that the vaccines were safe and effective, said Prof. Françoise Baylis, Canada Research Chair in bioethics and philosophy at Dalhousie University. The added wrinkle around the adjuvanted vaccine “was a case of bad knowledge exchange for decision-making, and that’s one of the lessons learned.”


“This is supposed to be about science, and the virus didn’t change when it crossed the border.”
Although pregnant women were not considered more likely to contract H1N1, specialists believed they would be at higher risk of severe pneumonia, hospitalization, early delivery, miscarriage, or pre-term birth if they were infected. Newborns would be more prone to infection, and could not be vaccinated in their first six months, making it even more important to vaccinate before birth.

Initial messaging from the Public Health Agency of Canada (PHAC) emphasized the safety of the vaccine, the dangers of H1N1, and the low risk of severe side-effects, and “suggested that these benefits were based on facts,” Baylis said. “But then, we got this lovely flip-flop,” with pregnant women advised to take the unadjuvanted vaccine up to 20 weeks’ gestation but the adjuvanted form in later stages of pregnancy.

“I’m sorry, but I would think there was something wrong with one of these two vaccines,” Baylis said.

The adjuvant was added to boost the body’s immune response, based on international concerns about manufacturing enough vaccine for a larger population. The confusion was compounded when PHAC and the Society of Obstetricians and Gynecologists of Canada issued conflicting advice on the matter, as did health officials from Canada, the United States, and the United Kingdom. The differences among the three countries were based largely on vaccine procurement strategies, she said. But “this is supposed to be about science, and the virus didn’t change when it crossed the border.”

Baylis said the case raised important questions about the role of science, politics, media, and health care providers in knowledge exchange, risk communications, and decision-making. But she expressed concern that the learning opportunity may be lost.

“In a lot of the circles I move in, the view is, ‘we did the best we could, don’t attack us.’” If that’s the response, “I worry that we will not be able to hear or learn.”

 

Prevention First

By Hon. Roy Romanow

It is difficult to overstate the importance of public health, and of a broader focus on the preventive side of health care. But sadly, our health system continues to place greatest emphasis on people’s well-being after an illness has struck.

It’s easy to be mesmerized by the outburst of new health care technologies. But important as they are, these medications and services must be balanced by pro-active governments and knowledgeable communities that bring an emphasis on prevention and public health to every neighbourhood and household.

Our health ultimately depends on the ability to make healthy choices, and the public health milestones of the last century have taken us in the right direction. Safe drinking water, improved housing and nutrition, and routine immunization have all made huge contributions to human well-being. But look no farther than the appalling health conditions in First Nations and Inuit communities across Canada for evidence of the disparities that have yet to be addressed. These disparities are about health outcomes. But they also reflect a broader income gap that is becoming more severe across our society, gradually choking many Canadians’ access to adequate housing, nutrition, education, and other basics that ultimately influence health.

Initiatives like the Canadian Index of Wellbeing connect the dots between the health of Canadians and the policies that help households and communities succeed, by linking community experience and awareness with official data. CPHA has consistently championed this kind of evidence-based advocacy, and we need more of the pro-active policies that have resulted.

Hon. Roy Romanow was Premier of Saskatchewan from 1991-2001 and chaired the Royal Commission on the Future of Health Care in Canada in 2001-2002.
 

Wanted: Healthy buildings, healthy communities

It takes many experts to design a healthy neighbourhood. Architects, city planners and engineers are obvious choices, but landscape architects, environmental psychologists, acoustics experts, academics, graphic designers, industrial designers, geographers, and public health workers all play key roles, attending to the small but crucial details.
 

In The Halls

“We know some major things have been done to improve quality of life through improved sanitation, water, and vaccination. But there are huge disparities that need to be brought to the forefront, particularly with indigenous populations, and we have to make the assimilation into Canada an easier transition for newcomers. The state of health for many Aboriginal populations is disgraceful in a country that is so rich in resources.”
—Toronto

Integrating these disciplines can pose significant challenges to building healthy communities, said Dr. Jennifer Veitch of the National Research Council’s (NRC) Institute for Research in Construction. The NRC’s new Canadian Building and Health Sciences Network hopes to change that by providing a forum for sharing ideas across disciplines.

Lack of leadership on the part of funding agencies, the tendency toward short-term thinking, and a lack of incentives and rewards can create further impediments to building healthy communities, said Dr. David Witty, University of Manitoba.

Canadians spend 90% of their time indoors, said Dr. Trevor Hancock of B.C.’s Ministry of Healthy Living and Sport, noting that this underscores the importance of healthy buildings. Although the public has shown interest in moving toward healthier buildings in healthier neighbourhoods, few communities are actually building them.

Design is fundamental to what people do and how they feel. For example, walkable neighbourhoods encourage social interaction and lower obesity rates, Dr. Hancock said, while noise affects speech development in children, and light exposure affects mood. It’s a matter of pulling it all together to create healthier environments, panelists agreed.

 

Integrating programs to enhance effectiveness

Universal and targeted initiatives can be used to avoid perpetuating existing inequities, said speakers at a session on applying a population health lens to public health planning.


“There is never enough data; we have to use our best assumptions to move forward.”
While broad-based programs like the Healthy Schools initiative can benefit from a cascading effect when paired with strategies designed for at-risk populations, multiple programs often address the same determinants of health, but are geared to distinct sectors of the population. Integrating multiple programs would enhance their combined effectiveness.

In The Halls

“The single greatest achievement is clean water, although we still need to do a lot of work on that. Globally, we know a lot of communities don’t have clean water services, so while westernized countries have the use of that technology, we don’t have it globally. For the future, the aging population is huge. Many of the health promotion things we do are geared much more to younger age groups, and this aging demographic is kind of forgotten.”
—Thunder Bay

Bernie Paillé and Andrew Taylor, both of the Canadian Institute for Health Information, described the use of the integrated population health promotion model. This tool helps users plan an initiative by systematically identifying how to engage the appropriate sector of the population around an indicated determinant of health.

Participants familiarized themselves with the tool, working in small groups to design an intervention based on a hypothetical scenario. They discussed the type of evidence that would be needed to give health officials confidence that the scale of their initiatives matched the scale of the health concern.

Some participants said the data provided were insufficient to make a decision about an intervention.

“This is a challenge in our work,” Taylor said. “There is never enough data; we have to use our best assumptions to move forward.”
 

Bernie Paillé of the Canadian Institute for Health Information answers questions during a Tuesday morning session on practical strategies for promoting health and reducing inequalities.  

Participants identify top priorities for action

Aboriginal health, environmental justice, control of psychoactive substances, a ban on chrysotile asbestos, climate change, and the drive toward global health governance were among the hot topics at CPHA’s second annual policy forum Tuesday afternoon.

“We know that the social determinants of health significantly influence the health of individuals, communities, and populations, within and beyond jurisdictions,” said Policy Director Jim Chauvin. But “in reality, the implementation of these concepts in Canada and in many other countries lags far behind the rhetoric.” When Chauvin and CPHA Chair Dr. Cory Neudorf opened the floor for discussion, participants suggested several priorities for action—and many volunteered to help with the required research and advocacy.

The group expressed strong support for action on Aboriginal health. “It’s very distressing that this country accepts the health disparities between Aboriginal Canadians and Canadians in general as part of our landscape,” said one participant. “I wonder about the concept of public health triage,” to prioritize Aboriginal people as the group with the worst health disparities in Canada.

Several participants stressed the link between the social determinants and environmental justice. “Since we’ve just come through a highly successful 100 years,” suggested one speaker, “why don’t we call next year’s conference ‘The Next 100 Years: Factoring in Our Environments?’ That could go for our social environment, our natural environment, our built environment, and even our virtual environment.”

A participant said the tobacco tax exemption for First Nations represents a disparity that “separates out an ethnic group for unequal or unjust outcomes.” Another participant said CPHA could only tackle that issue in partnership with Aboriginal organizations.

A participant presented a resolution on chrysotile asbestos, endorsed by several leading health and environment organizations, including CPHA. Board member Dr.  Lynn McIntyre pointed out that CPHA has an established process for endorsing statements and campaigns by other groups.
 

Moving public health up the agenda

“You must keep your integrity; speak honestly—when you don’t know something, say you don’t know.”
An overflow crowd heard five public health and policy leaders take on difficult questions about navigating their roles as government officials charged with protecting the public’s health.

Dr. David Butler–Jones, Canada’s Chief Public Health Officer, said the role involves offering “fearless advice and loyal implementation” in a way that is “intensely political but not partisan.” The challenge is to get politicians to care about events that extend beyond their immediate interests, he said.

Public health tends to lose out to crisis management and disease-specific campaigns when it comes to government support, said Mel Cappe of the Institute for Research on Public Policy (IRPP). Perry Kendall of B.C.’s Ministry of Healthy Living and Sport agreed, noting public health authorities should respond by drawing a connection for the public between crises and the need for improved care for chronic conditions.

Effective use of the media is paramount to moving public health further up the government’s agenda. It is crucial to remain a credible source of information, said Dr. Butler–Jones: “You must keep your integrity; speak honestly—when you don’t know something, say you don’t know.”

André Corriveau, Alberta’s Chief Medical Officer of Health, pointed out that finding new ways to communicate with the younger generation means making better use of social media, which in turn will require health authorities to engage in public dialogue, rather than simply making pronouncements.

During the question period, some participants expressed disappointment over the panel’s composition. Community-level organizations were not represented, although many public health initiatives originate at the community level, said one participant. Another noted the panel’s lack of women and visible minorities.

 

Communities must define public health needs

Public health must focus on communities’ needs—as assessed and described by those communities—and build upon them, said speakers during a Tuesday afternoon session. Institutions can build trust by meeting a community’s stated needs before addressing needs perceived by authorities.


“These are things we need action on, not just apology.”
Describing a recent conference where academics, researchers, and representatives of the Aboriginal community discussed respiratory and cardiovascular risk, Dr. Malcolm King of the Canadian Institutes of Health Research (CIHR)—Institute of Aboriginal Peoples’ Health said that while the academics identified smoking, diet, and exercise as target areas, Aboriginal community members spoke to poverty, education, unemployment, and housing.

“Public engagement results in better information, and hopefully better policy and practice,” Dr. King said.

“Who is going to answer the call with respect to poverty, education, unemployment and housing?” asked Dr. Françoise Baylis of Dalhousie University. “These are things we need action on, not just apology.”

Dr. Ann Macaulay of McGill University called the process of change one of “co-learning.” Noting the importance of collaboration, She described a Mohawk community in Quebec that had developed a healthy nutrition policy in its schools.

“Redefining the acceptable” is the philosophical foundation of the moral values underlying public health, said Dr. John Last of the University of Ottawa: “I hope it will soon be morally unacceptable to ignore stress signals like suicide in young Native people, nutritional deficiencies in old people, or drug use in street people.”

 

Collaboration, leadership help build public health organizations

Public health systems are wrestling with systemic problems in the work force, and trying to anticipate the needs of the system, said Ron de Burger of Toronto Public Health. In a session on public health human resources, de Burger outlined some of the challenges, including critical shortages in quantity and distribution of workers, varying approaches to training, and the need for improved links with academia.


“Individual competencies are important...but we apply them in an organizational context.”
“We’ve spent considerable effort in the development of core competencies,” said public health consultant Dr. Brent Moloughney, “but while individual competencies are important, the reality is that we apply them in an organizational context.” Dr. Moloughney defined organizational competency as “the key sets of processes within organizations that turn the collectivity of individual skills and other assets into useful effect.”

Other speakers spoke to the challenges their organizations had faced in implementing organizational change. “Leadership is vital,” said Rachel Roberts of the Public Health Agency of Canada, noting that change management depends on the hierarchy buying into the change, feedback traveling up and down the hierarchy, and resources being made available to support the change.

Caroline Ball of Hamilton’s Public Health Services stressed the importance of external collaboration and relationship building. Information exchange with other public health units and organizations has been “a real driver to our success,” she said.

Responding to a participant’s question about relationships with universities, Dr. Moloughney said universities “need to be involved on an ongoing basis with the professional development of graduates.”

 

Value users’ experiences, insights

Public health programs must reflect the real lives of those who use the system, said presenters during a session on advocacy from the ground up. Three women—veteran users of community-based programs that helped them overcome challenges in their lives—described how moving into advocacy roles had helped them heal personally. They said real advances in public health will take place only when officials, policy-makers, and academics recognize users’ lived experience as equivalent to academic and professional expertise.


“The advocacy [of service providers] was pivotal to my survival and recovery.”
Nadia Edwards recalled crying during her first pre-natal class at The Stop Community Food Centre because she was so relieved to find a safe space to talk about her domestic turmoil.

Linda Coltman, a member of Toronto’s Voices from the Street, was diagnosed with renal failure when she was a teen; she subsequently “fell through the social safety net multiple times.” She said that public health officials at all levels must respect the experience of those they wish to help. Advocacy in this sector grows more essential every day, as “people have fallen farther now; they are dealing with lots of systemic issues.”

Identifying herself as a consumer/survivor, Jane Anglin of YWCA Toronto’s Choices for Living said organizations that separate experts from volunteers often suffer from a lack of empathy. This has real impact on people’s lives, she said, noting that the “the advocacy [of service providers] was pivotal to my survival and recovery.”

 

Funding key to successful immunization programs

“Topping the list was a need for sustainable and predictable funding. Some suggested that the federal government should take a leadership role...”
As new vaccines enter the market in unprecedented numbers, stakeholders in government, industry, and public health face new challenges and opportunities, said Dr. David Allison, chief medical officer of health, Eastern Regional Health Authority, Newfoundland. “We need to articulate a common understanding of the issues, and determine an optimal framework for new developments,” he said, during the session on advancements in immunization.

Participants offered comments on the 2009 CPHA report, “Setting the Stage for Advancements in Immunization in Canada,” which summarizes an invitational roundtable series. During breakout sessions, stakeholders discussed the key issues and priorities contained in the CPHA report.

Topping the list was a need for sustainable and predictable funding. Some suggested that the federal government should take a leadership role, purchasing the vaccines upfront and coordinating their delivery through the provinces and territories.

Participants identified a national immunization registry as another major priority. A crucial surveillance tool, the registry would ensure that all segments of the population receive equal access to vaccines.

Despite epidemiological differences among the provinces, a harmonized vaccination schedule is high on the wish list. Last year’s roundtable suggested that a consensus on a national model should be achieved by the beginning of 2012.

The vaccine approval process would be hastened by reducing duplication and overlap within review committees. Industry representatives said they would welcome transparency within bureaucratic decision-making, and more partnerships among key stakeholders would foster greater collaboration in vaccine development.

The Daily is the official newsletter of the Centennial Conference of the Canadian Public Health Association, June 13-16, 2010 in Toronto. Views expressed are those of the individuals and organizations cited.

Editor in Chief: Judy Redpath, CPHA
Editorial and Production: The Conference Publishers, www.theconferencepublishers.com
Photo: Bard Azima, LivingFace Photography